“Cognitive Behavioral Therapy for Binge Eating Disorder” was presented at the Minnesota Psychological Association’s First Friday Forum on January 8, 2016. Drs. Koball and Grothe focused on discussing diagnostic criteria for binge eating disorder, reviewed recent research on the efficacy of CBT for binge eating disorder, and described specific CBT skills using pertinent case examples. Finally, they offered information on behavioral weight management for individuals who are in remission from binge eating disorder, but who desire further weight-related intervention.

Binge Eating Disorder (BED) is characterized by episodes of eating in a discrete period of time (e.g., within 2 hours) a larger amount of food than what most people would eat in a similar period of time under similar circumstances (e.g., 4 bowls of cereal, 1 pint of ice cream). Additionally, individuals with BED experience a sense of lack of control over eating during the episode(s) (e.g., feeling that one cannot stop eating or control what or how much one is eating). Furthermore, to meet criteria for BED, binge eating episodes must be associated with 3 or more of the following: 1) eating much more rapidly than normal, 2) eating until feeling uncomfortable full, 3) eating large amounts of food when not feeling physically hungry, 4) eating alone because of feeling embarrassed by how much one is eating, and/or 5) feeling disgusted with oneself, depressed, or very guilty afterward. Finally, marked distress regarding binge episodes must be present to meet diagnostic criteria, binge eating must occur on average at least once a week for 3 months, and binge eating is not associated with recurrent compensatory behaviors (e.g., vomiting or laxative use; APA, 2013). Today, BED is more common in the U.S. than anorexia nervosa or bulimia nervosa, occurs in approximately 3-5 % of women and 2% of men, and is commonly associated with other mental health conditions including low self-esteem, borderline personality disorder, substance abuse, and depression (ANAD, 2012). Individuals who engage in binge eating often struggle to balance eating, and may cycle between periods of significant restrictive eating, episodes of binge eating, and severe guilt and shame.

One of the gold standard treatment approaches for BED is Cognitive Behavioral Therapy (CBT) which targets problematic behaviors associated with binge eating (e.g., restrictive eating, binge episodes, irregular eating) and cognitive factors (e.g., all/nothing thinking patterns, body shame). A wealth of research has suggested that CBT is an efficacious treatment for individuals experiencing BED as well as those with sub-threshold binge eating (e.g., Grilo, 2012; Wilfley, 1993). CBT sessions generally follow seven steps, as guided by Fairburn’s 2013 book (a great self-help resource for patients as an adjunct to their treatment; Fairburn, 2013).

Step 1. Patients are encouraged at the onset of treatment to monitor their food and drink consumption to learn more about problematic eating patterns that may be contributing to binge episodes. Individuals with BED often experience periods of restriction followed by binges. By documenting eating habits, individuals develop more insight into these patterns.

Step 2. Next, individuals are asked to add structure to their eating, never going more than four hours without eating. For example a patient may choose to structure their eating as follows:

6:00 am: Breakfast

9:30 am: Midmorning snack

12:00 pm: Lunch

3:00 pm: Midafternoon snack

6:30 pm: Evening meal

8:30 pm: Evening snack

This structuring helps patients to avoid the binge/restrict cycle, regulates hunger/satiety signals, and helps to reduce shame/guilt associated with eating.

Step 3. Given that binge eating often serves as a coping mechanism for underlying psychological distress, as patients progress in treatment, they may find that they are left with fewer resources to cope with life stressors now that food is no longer used in this way. Thus, the next step of treatment is focused on helping individuals to develop coping strategies to tolerate distress such as distraction techniques (e.g., calling a friend) or mindfulness, for example.

Step 4. Problem solving is another way that individuals can learn to cope better with life stressors and also to avoid the urge to binge. Together with the therapist, patients can work to identify problems early, specify the problem accurately, consider solutions to the problem, think through implications, choose the best solution, and act.

Step 5. Many patients have experienced an improvement in their binge eating by this point in treatment, and taking stock of this progress is helpful in establishing remaining treatment goals.

Step 6. Given that individuals with BED often experience significant dieting history and/or body image distress, this is typically a worthwhile area to target next in treatment. Utilizing thought monitoring, reframing, and challenging, patients can become more aware of automatic thoughts and work to balance this thinking that is likely impacting their eating behaviors and mood. Behavioral activation, especially focused in areas that utilize the body for its function, rather than as an appearance object, can also help improve dieting behaviors and body image. Finally, development of a mindfulness practice and or gratitude journaling can be helpful for these issues.

Step 7. At the end of treatment, reviewing and reinforcing progress is important. Additionally, development of motivational strategies and relapse prevention techniques can also be key in avoiding redevelopment of binge eating. Tapering sessions and allowing for yearly follow-up will help individuals stay connected to their treatment goals.

For those individuals who are in full remission from BED, or who struggle with subthreshold binge eating in their efforts at weight loss, behavioral weight management strategies grounded in empirical foundations can be helpful. Individual or group interventions that focus on self-monitoring (e.g., food diary, activity tracking, and/or weekly weighing), goal setting, mindful eating, stimulus control, stress management, social support, and cognitive restructuring have been shown to be most effective (Butryn, 2011; Wadden, 2000). Self-monitoring has long been suggested as the best predictor of weight loss and weight maintenance over the long term (Butryn, 2007) and is a great place to start in helping patients to better manage eating practices and weight.

There are various resources available to providers and patients including The National Eating Disorders Association (http://www.nationaleatingdisorders.org/) and the National Association of Anorexia and Associated Disorders (http://www.anad.org/). Additionally self-help resources are available including “Overcoming Binge Eating” by Christopher Fairburn, “The Body Image Workbook” by Thomas Cash for binge eating treatment, “The LEARN Manual” by Kelly Brownell, and “The Mayo Clinic Diet” for weight management.

Afton Koball, Ph.D., L.P., graduated with a Ph.D. in clinical psychology from Bowling Green State University. Dr. Koball’s primary research and clinical interests are in behavioral intervention for obesity and eating disorders. Her work has focused on psychological correlates of behavioral and surgical weight management, food addiction, weight bias, and patient-provider communication about weight.

Karen Grothe, Ph.D., L.P., ABPP, graduated with a Ph.D. in clinical psychology from Louisiana State University. Dr. Grothe’s research and clinical work has focused on psychological factors that influence health and health behaviors. In particular, she has examined psychosocial aspects of weight loss surgery, obesity and physical activity, especially those that predict outcome or influence adherence to medical recommendations.

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